Patient Safety Policy and Procedure Team Update Team Members - PowerPoint PPT Presentation

Just Culture: Accountability for Patient Safety Policy and Procedure Team Update

Team Members • Lisa Bonacci (co-chair), Vice President, HR Services and Operations • Joanne Sorensen (co-chair), Director, Care and Quality Management • Chris Cepullio, Patient Safety Coordinator • Linda Conroy, Director, Accreditation & Regulatory Compliance • Glenda Davis, Director, PCS Administration • Mark Frick, Vice President, Human Resources • Tony Gigliotti, Program Director, Talent Management • Lisa Painter, Director, Risk Management • Chaton Turner, Assistant Counsel 2

Team Objectives • Create an algorithm that provides: – a structured process to guide managers through the evaluation of an event or near miss; – an outline for conducting an investigation of an event by posing critical questions; – a decision tree for identifying system failures and human errors; and – a tool for assessing accountability (remedial, punitive, etc.) for those involved in an event. • Ensure that key UPMC policies support the Just Culture philosophy. 3

Our Duties • Duty to produce an outcome – Applies when an individual knows the desired outcome and should be able to produce it (e.g. the safe removal of an appendix or urinary catheter) • Duty to follow a procedural rule – Applies when an individual knows the proper procedure and it is possible to follow the rule • Duty to avoid causing unjustifiable risk or harm – Breach of this duty occurs when an individual intentionally harms the patient or acts recklessly Reference: California Hospital Patient Safety Authority, (2010) Accessed January 20, 2011 @ http://www.chso.org/just/index.asp 4

UPMC Just Culture Algorithm: Key Questions • Four key questions guide investigation of an event: – Were the actions as intended? – Does there appear to be evidence of ill health or substance abuse? – Did the individual depart from agreed protocols and/or safe procedures? – Would another individual coming from the same professional group (within or outside UPMC), possessing comparable qualifications and experience, behave in the same way in similar circumstances? 5

UPMC Just Culture Algorithm: Outcomes Type of Behavior Behavioral Definition Possible Outcomes Malicious behavior Harm was intentional. Corrective action (including discharge), legal proceedings Unfit for duty Performance is impaired by illegal or Fitness for Duty Policy legal substances; cognitive or physical impairments; other health issues; and/or severe psychological stressors. Reckless action Rules are knowingly violated, and/or a Corrective action, retraining, dangerous/unsafe decision was made. teaching others Risky action Potentially unsafe choice was made. Coaching, teaching others, corrective action (for repeated issues) Individual human Human error was made, and/or system Consoling, fixing system error or system infrastructure increased chances of error. issues, communicating to failure staff, retraining, coaching 6

DRAFT 7

Under Review • Corrective Action and Discharge Policy • Performance Management Policy • UPMC Code of Conduct • UPMC Patient Safety Plans 8

Questions and Feedback 9

Patient Safety Policy and Procedure Team Update Team Members - PowerPoint PPT Presentation

Just Culture: Accountability for Patient Safety Policy and Procedure Team Update Team Members Lisa Bonacci (co-chair), Vice President, HR Services and Operations Joanne Sorensen (co-chair), Director, Care and Quality Management

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Patient Safety Policy and Procedure Team Update Team Members - PowerPoint PPT Presentation

Just Culture: Accountability for Patient Safety Policy and Procedure Team Update Team Members Lisa Bonacci (co-chair), Vice President, HR Services and Operations Joanne Sorensen (co-chair), Director, Care and Quality Management

The UCLPartners Patient Safety Programme: Update Peter Toohey, Patient Safety Improvement Manager,

Behavior Patient Safety Connection Behavior Patient Safety Connection Does Any Doubt Remain?

prevention? Dr Frances Healey , RN, PhD, Deputy Director of Patient Safety (Insight) September

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